Describe a depressed patients thoughts with respect to past, present and future
Past: thinking of the past can include feelings of guilt and self blame out of proportion to the circumstances
Present: thoughts of low self esteem and confidence
Future: idea of the future is viewed with ruin and misfortune
-can lead to suicidal thoughts
What are the biological/somatic symptoms of depression?
Loss of appetite
Early morning weakening (at least two hours earlier than normal)
Diurnal mood variation (worse in the morning)
Low energy
Weight loss (5% or more of body weight lost in the last month)
Marked loss of libido
Psychomotor retardation (patient is slowed down)
What are the appearance changes of depression?
Evident neglect of dress and grooming
Facial features- downward turning of the sides of the mouth
-furrowing of the centre of the eyebrows
Reduced rate of blinking
Shoulders bent forward
Head inclined forwards
Patient looks downwards
Poor eye contactName 5 other presentations
Agitation Masked depression Atypical depression Mania Psychotic symptoms
Define agitation
Restless and irritable
Define masked depression
When patient doesn’t obviously look depressed and often denies being in low mood
Define atypical depression
Patients show symptoms like weight gain, decreased appetite, increased sleeping time, together with increased fatigue and variable mood disturbances.
Can be with anxiety
Define psychosis including two psychotic symptoms
When patient has lost touch with reality.
Includes delusions and hallucinations
Define delusions
Firmly held ideas or beliefs on inadequate grounds, and not in keeping with patients cultural background.
Define hallucinations
False perceptions
What is the most common type of hallucination
Auditory
What is the central feature of mania?
Elevated mood
What does hypo mania mean?
Lesser degrees of mania with less severe symptoms
What is the lifetime risk of bi-polar disorder
0.5-1.5%
What are the symptoms of mania?
High in energy (overactive)
Ideas of high self-importance
Rapid speech, sometimes the patient can’t stop talking, this is known as pressure of speech
Increased sexual desire
Flight of ideas, a rapid sequence of ideas
Reduced sleep
Patient has the impression that his mind is working faster than usual
Patients feel cheerful and generally optimistic about the future
But sometimes patients are irritable rather than euphoric
Delusions and hallucinations
-delusions of possessing certain talents or of being particularly important or rich
-hallucinations tend to be auditory and positive
What is classification of mood disorders outlined in?
The ICD 10
How are depression episodes divided?
Mild
Moderate
Severe
Severe with psychotic symptoms
What is recurrent depressive disorder?
Where depression is viewed as a condition that is repetitive during a lifetime
How is mania divided?
Hypo mania
Mania
Mania with psychotic symptoms
What constitutes bipolar affective disorder
2 or more episodes of elevated mood and/or 1 episode of lowered mood
What is dysthymia?
A chronic lowered mood, not quite meeting the criteria for clinical depression
What is cyclothymia?
A persistent instability of mood not quite reaching the criteria for bipolar disorder
What is the point prevalence for depression symptoms between?
13-20%
Who are depressive symptoms more common in, men or women?
Women
Which social class is at highest risk for depression?
Lower
What’s the lifetime risk of depressive illness estimated as?
5-17%
How are causes of mood disorders divided?
Precipitating
Predisposing
Maintaining
Define a precipitating cause
Events that lead directly to the episode. Often due to loss.
Give 3 examples of types of loss.
Loss of a loved one death, divorce etc.
loss of a job
Loss of good health
Define a predisposing cause.
Relating to someone’s psychological make up.
Give two examples of predisposing causes of depression
Genetics
Childhood experiences
Define a maintaining cause
A chronic stressful situation
Give three examples of maintaining causes for depression.
Marital disharmony
Financial strain
Alcohol/drug abuse
How can causes of mood disorders be further divided? Defining each one.
Biological- relating to genetics and changes in brain neurochemistry
Psychological - relating to how people view themselves, the future and the world around them
Social support - relating to someone’s social support, financial situation, hobbies and habits
What is the function of the frontal lobe of the brain?
Decision making and movements
What is the function of the temporal lobe of the brain?
Emotion and primary auditory cortex
What is the function of the parietal lobe of the brain?
Sensation
What is the function of the occipital lobe of the brain?
Visual
How have we found out about which parts of the brain are involved in mood disorders?
Brain surgery Stroke Imaging Rabies of he limbic system Lesions inflicted on animals
What are the core symptoms of depression?
Pervasive low mood for at least two weeks
Lack of enjoyment and interest in activities normally liked by the patient
A lack of energy
What structures are involved in mood disorders?
Striatum Neocortex: prefrontal cortex Limbic system (important for emotion, motivation and memory) -cingulate gyrus -hippocampus -amygdala -hypothalamus
Where is the cingulate gyrus?
Part of temporal lobe
What is the importance of the hippocampus?
Involved in motivation, emotion and memory
What is the importance of the amygdala?
Critical for conditioning and emotional processing
Has inputs from many sensory areas
Connected to areas of- autonomic function
- motor function
- neuro-endocrine function
What image techniques can we use to look at the brain?
MRI CT fMRI SPECT PET
What do MRI scans look at?
White matter changes
How do white matter changes relate to treatment?
White matter changes = poorer response to treatment
Name a structure that can be measured by MRI?
Hippocampus
What happens to the hippocampus in Alzheimer’s disease?
It gets smaller
What happens to the hippocampus in depression?
It gets smaller
How does hippocampus reduction correlate with depression?
Increased reduction = increased duration of illness
What are the two types of illness in psychiatry giving examples?
Organic - dementia, delirium
Functional - depression, schizophrenia, anxiety disorders
What does an fMRI look at?
Difference between oxygen rich and oxygen poor blood flow
Thus measures neuronal activity in brain and spinal cord
In depression under fMRI which areas of the brain are abnormal?
Amygdala and cingulate gyrus.
Which changes shown by imagery are reversed by CBT?
Amygdala and cingulate gyrus in fMRI
How do pet and spect scans work?
emitting gamma radio-isotopes
Cameras detect emitting radiation and computers quantify
What do PET and SPECT scan look at?
Blood flow
Neuronal activity
Receptors
What is the prefrontal cortex composed of?
Ventro medial prefrontal cortex
Lateral orbital prefrontal cortex
Dorso lateral prefrontal cortex
Which prefrontal cortex areas malfunction in depression? And how?
VMPFC - hyperactivity = increased sensitivity to pain, anxiety and depressive rumination
DLPFC - hypo activity = psychomotor retardation, apathy and attention deficits
How else can the prefrontal cortex malfunction?
Disconnection with the limbic system leads to dis regulation of emotional control
What areas are effected in depression wrt neuro endocrine changes?
Cortisol/HPA axis
Growth hormones
Thyroid
How is the cortisol HPA axis affected in depression?
Increased levels of cortisol
What structural change is dis regulation of cortisol HPA axis associated with?
hippocampus atrophy
What change happens wrt growth hormones in depression?
Blunted response to growth hormones
What change happens wrt the thyroid in depression?
Incipient hypothyroidism
TSH response to TRH is blunted
Name a hormone sometimes used in depression
Thyroxine
What happens to cytokines in depression?
Over activity
What causes the changes in cytokines in depression?
Increased sympathetic tone - HPA axis over activity and amygdala dis regulation
What are the effects of the cytokine changes in depression?
Fatigue Loss of appetite Loss of libido Hypersensitivity to pain Disrupt other hormone systems ie. Blood glucose control
Which neurotrophic factors are affected by depression and how?
Brain derived neurotrophic factor is decreased
BDNF
What is the role of BDNF
Cell maintenance and plasticity in the brain
What parts structures of the brain does low BDNF affect
Hippocampus reduction
Limbic system
Which neuro endocrine systems are affected by reduced BDNF and how?
HPA axis as a result of hippocampus reduction
What is the importance of REM sleep?
Important for psychological therapy
What is the importance of NREM sleep?
Recovery of muscles and other parts of the body
What is a hypnogram?
Graph that represents the stages of the sleep cycle
How is sleep architecture affected in depression?
REM latency is reduced from 35 mins to 18 mins
What is REM latency?
Time between the start of sleep and the first onset of REM sleep
How can sleep architecture be restored?
Anti-depressants
What are the cognitive therapy rationale?
We are not passive recipients of stimuli
We interpret the world via beliefs, attitudes, expectations and values
We use cognition a to make sense of the world
It’s not situations that upset us but the view we take of them
Changes of mood are linked directly to the way we make sense of events
How do the cognitive therapy rationale translate into a schemata?
Event/situation➡️thoughts➡️emotionls
Draw out the cognitive model
Thoughts
↗️ ⬆️ ↖️
↙️ ↘️
Physiology ⬅️ ➡️ Emotions
↖️ ↗️
↘️ ⬇️ ↙️
Behaviour
↗️
Environment
Also called hot cross bun model
What is the negative cognitive triad?
Negative view of self
Negative view of the world
Negative view of the future
What does this refer to I am... ⬇️ If I do this then this will happen ⬇️ I should.. Or else...
Core belief (schema) ⬇️ basic assumption ⬇️ Conditioned schemata
Give 5 core beliefs
Love- I'm unloveable Ability- I'm incompetent Morality- I'm evil Normality- I'm a freak Worth- I'm worthless
Give 5 examples of basic assumptions
Everybody must love me
Either I am 100% successful or a total flop
I must always be nice
If people disagree with me then I am no good
I should be able to do everything, to ask for help is weak
How are core beliefs and basic assumptions formed?
Early experiences ⬇️ Core beliefs ⬇️ Basic assumptions
What does NATs stand for?
Negative automatics thoughts
Give four examples of NATs
Low self esteem
Guilt and self blame
Hopelessness
Suicidal thoughts
What is the basis of activity scheduling in CBT?
Record activities regularly
Give a mastery rating 0-10 (sense of satisfaction)
Give a pleasure rating 0-10
What is the basis of thought challenging in CBT?
Discussing thinking errors
Draw out the ‘doing nothing’ cycle
NATs- self defeating thoughts
↗️ ↖️
↙️ ↘️
Physical signs of depression Emotions- self-defeating emotions
↖️ ↗️
↘️ ↙️
Self defeating actions
Give the 12 thinking errors and define them
All or nothing- you see a situations as two categories rather than a continuum
Discounting the positive- unreasonably tell yourself that positive feelings, qualities and deeds don’t count
Mental filter - only pay attention to the negative aspects and don’t look at situation as a whole
Emotional reasoning- because you strongly believe something it must be true, ignoring evidence to the contrary
Mind reading- assuming you know what others think without taking taking into consideration other possibilities
Overgeneralisation- making a negative conclusion that goes beyond the current situation
Catastrophising - predicting the future negatively without consider more likely possibilities
Tunnel vision - only see negative side of a situation
Labelling - putting fixed labels on yourself or others without considering evidence that may lead to a less disastrous conclusion
Magnification/minimising - magnify the negatives/minimise the positives
Imperatives you create an precise eyes of how others should behave and overestimate how bad it is that these expectations aren’t met
Personalisation - you assume that when others behave badly it is because of you without considering more likely explanations
What types of studies have been used to look at genetics of affective disorders?
Family
Twin
Adoption
Sex differences
What are the methodological issues of studies looking at genetics in mood disorders?
There is no biological diagnosis of depression, diagnosis is made on symptoms
Depression is inherited via quanta time trait loci (many different genes)
Genetic factors can change a persons sensitivity to traumatic events
Genetic factors have an effect a persons environment
What are the two main neurotransmitters in mood disorders?
Nor-adrenaline
Serotonin
Give 4 other neurotransmitters involved in mood disorders.
Dopamine
Acetylcholine
GABA
Glutamate
What is the role of Nor-adrenaline in the brain?
Has an effect on behaviour - arousal and attention
Has a memory function
Where is Nor-adrenaline made and transported to?
Made in the coeruleus locus and transported to various areas of the cortex
Where is the coeruleus locus
Between brain stem and limbic system
What are the different receptors of Nor-adrenaline?
Alpha 1&2
Beta 1&2
Which noradrenaline receptors have the biggest association with mood disorders?
Alpha- role in mood and arousal
What is the evidence for noradrenaline involvement in mood disorders?
AMPT -inhibits tyrosine➡️L-DOPA thus reducing noradrenaline. This leads to depressive symptoms
Successful anti depressants have increasing noradrenaline effects on the synaptic cleft
- NARI - noradrenaline re uptake inhibitors
- SNRI - serotonin and noradrenaline re uptake inhibitors
- tricyclic antidepressants - inhibit reputable of serotonin and noradrenaline
What is the role of serotonin in the brain?
Sleep
Impulse control
Appetite
Mood
Where is serotonin produced and transported to?
Produced in Raphe nucleus of the brain stem and transported to the limbic system and cortical areas
What is the evidence for serotonin involvement in mood disorders?
Tryptophan (serotonin precursor) depletion causes depression
5HIAA (serotonin metabolite) is deleted in depressed patients
Post mortem studies show less serotonin secretion in the brain of depressed patients
PET scans show decreased 5HT1A receptor binding in the brain of depressed patients
SPECT scans show decreased 5HT re uptake sites in the brain of depressed patients
Successful anti depressants have increasing serotonin effects on the synaptic cleft
- SSRI - serotonin selective re uptake inhibitor
- SNRI - serotonin and noradrenaline re uptake inhibitors
- tricyclic antidepressants - inhibit reputable of serotonin and noradrenaline
What does dopamine release do?
Give feeling of pleasure
What disease is dopamine associated with?
Parkinson’s
Which therapy has a big affect on dopamine?
ECT
Which hypothesis links serotonin, noradrenaline and dopamine to depression?
The mono-amine hypothesis
What roles does acetylcholine have?
Memory
Sleep
Addiction
How is GABA made?
Synthesised from glutamate
What type of neurotransmitter is GABA?
Inhibitory
What is GABA’s function?
Inhibits chloride transport
When is ECT used for depression?
As a second line treatment
Intolerable to antidepressants
In a matter of urgency - ie suicidal
What else is ECT used to treat?
Mania
Schizophrenia
Puerperal psychosis (postpartum)
What are the NICE guidelines for depression?
Only used for rapid short term improvement
If other treatments have failed or if it is a life threatening situation
For a severe depressive episode
For sever or prolonged manic episode
Describe the procedure
Brief square wave impulses transmitted unilaterally via electrodes on the temples
What are the side effects of ECT?
Retrograde or anterograde amnesia Status epliepticus (epileptic seizure) Laryngispasm Peripheral nerve palsy Cardiac effects
Define secure attachment
Caregiver is sensitive and responsive to child’s needs
Define avoidant attachment
Caregiver is rejecting or intrusive
Define disorganised attachment
Caregiver is unpredictable or frightening
Define resistant ambivalent attachment
Care giver is inconsistent or neglectful
Also child abuse
What percentage of children experience each attachment?
Secure 60%
Avoidance 15%
Disorganised 15%
Resistant-ambivalent 10%
Give four factors that may affect attachment
Alternative child care
Divorce
Death of a parent
Parental mental disorder
How is bullying linked to depression?
Bullying is likely to cause depression in victims
Also bullies are more likely to become depressed in later life
Why are women more likely to be depressed than men?
Socio-occupational - child care is stressful and more likely to be a woman’s responsibility
Men are more likely to distract themselves thus less rumination
What psychosocial factors affect postnatal depression?
Loss of sleep Relationship with partner and/or farther Social adversity Difficulty of childcare role Obstetric complications
How does depression affect relation ships?
Depression = decreased self confidence and participation in social interaction
How does marital status affect depression?
Marital disturbance or divorce increases likelihood of depression
Lack of intimate relationships (marriage) increases likelihood of depression
Who is depression highest in, divorced or never married?
Divorced
What are the socioeconomic risk factors for developing depression?
Poverty
Low social class
Low level education
Isolation from friends and family
Which gender is unemployment a bigger risk factor for depression?
Men
When looking at life events leading to depression what else do we have to consider apart from the event itself?
Other ongoing difficulties
Other theories (attachment)
Level of available support
What does IPT stand for?
Interpersonal psychotherapy
In psychotherapy where can thoughts be stored?
Conscious - currently being thought about
Preconscious - not currently in the conscious but can be recalled if required
Unconscious - existing outside the conscious awareness and cannot be recalled
What makes up the structural model of the mind in psychotherapy?
The Id, superego and ego
Describe the id
The part of our mind that is driven by biological needs. It seeks instant gratification of desires and needs without regard to possible destructive consequences
Describe the superego
Evolves as an individual develops and internalises moral standards and what is dictated by authority figures
Describe the ego
Describes rationale, it is the reality orientated part of a personality
Employs defence mechanisms to protect integrity
Defence mechanisms are often unconscious
What are the seven ego defence mechanisms?
Projection Sublimation Reaction formation Splitting Suppression Acting out Introjection
Define splitting
Divided experiences and people into good and bad
Prevents a healthy integration of all aspects of others
Define projection
Projecting the internal conflict outside ones self
Define reaction formation
Doing the opposite of the initial desire
Define sublimation
Obtaining gratification in a more acceptable way
Define suppression
Consciously positioning an internal conflict for later
What are the four techniques used in psychotherapy?
Transference
Counter transference
Free association
Listening to the conscious and unconscious communication
What is transference and how is it used in psychotherapy?
Attitudes and feelings attached to past relationships are transferred into the therapist
Allows past experiences to be relived and explored safely
What is counter transference and how is it used?
Feelings and attitudes felt by the therapist in response to the patient
Allows therapist to see what feelings the patient evokes in others
What is free association?
Patient is encouraged to suspend judgement and report whatever comes into their mind
Expand on listening to conscious and unconscious communication
Therapist attentively listens to conscious and unconscious communication and makes interpretations in order to bring the unconscious into awareness
In psychotherapy what is melancholia?
Where person loses interest in reality and can’t recover easily
Where person believes they are inferior and despicable
What do SSRIs do?
Block re uptake of serotonin into the presynaptic neurone thus increasing concentration in the synaptic cleft
Give three examples of SSRIs
Citalopram
Fluoxetine
Sertraline
What are common side effects of SSRIs?
Nausea
Sexual dysfunction
Weight loss or gain
Hypotension
How do TCAs work?
Block re uptake of serotonin and noradrenaline into the presynaptic neurone thus increasing concentrations in the synaptic cleft
Give three examples of TCAs
Lofepramine
Amitriptyline
Clomipramine
Give five common side effects of TCAs
Cardio toxic - arrhythmic and heart block blurred vision Urinary retention constipation Dry mouth
How do MAOIs work?
They irreversibly inhibit the enzyme monoamine oxidase which breaks down serotonin and noradrenaline thus increasing their concentrations in the synaptic cleft
Give two examples of MOAIs
Phenelzine
Trancypromine
Give two side effects of MOAIs
Hypotension
Dizziness
How do SNRIs work?
Block re uptake of serotonin and noradrenaline into the presynaptic neurone thus increasing concentrations in the synaptic cleft
Give two examples of SNRIs
Venlafaxine
Duloxetine
Give three side effects of SNRIs
Nausea
Constipation
Hypertension
WhT are NaSSAs and what do they do?
Noradrenaline and specific serotonergic agents
Block alpha 2 adrenoreceptors on presynaptic neurone thus increasing serotonin and noradrenaline in the synaptic cleft
Which antidepressant is first line in cardiac patients and why?
SSRIs
Have potential anti arrhythmic effect
What should you do when prescribing antidepressants for hepatic or renal impairment patients?
Use lower starting doses
